Health Law Daily Wrap Up, ADMINISTRATION OF MEDICARE/MEDICAID PROGRAMS—DAB DECISIONS: 5-year exclusion upheld in Medicaid fraud personal care billing scheme, (Jun 10, 2026)

By WK Editorial Staff

The fraudulent billing for overlapping personal care services was related to the delivery of an item or service under Medicare or a state health care program.

An administrative law judge (ALJ) for the HHS Departmental Appeals Board (DAB) has upheld the mandatory five-year exclusion of a Minnesota personal care assistant from Medicare, Medicaid, and other federal health care programs after concluding that the fraudulent Medicaid billing scheme fell within the broad exclusion authority (Payne, DAB No. CR6789, Doc. No. C-25-644 (Nov. 5, 2025)).

False billing. The case arose from allegations that the caregiver, who worked as a personal care assistant, billed Minnesota’s Medicaid program for personal care services purportedly delivered to multiple patients at the same time. State prosecutors alleged that the overlapping billing occurred repeatedly over more than two years and generated more than $33,000 in improper payments. The caregiver ultimately pleaded guilty to two counts of theft by false representation under a negotiated agreement that included restitution and probation.

Conviction. Although the state court stayed imposition of the felony sentence and contemplated eventual misdemeanor treatment upon successful probation completion, the ALJ emphasized that federal exclusion law uses an intentionally broad definition of “conviction.” A guilty plea accepted by a court is enough to trigger exclusion authority regardless of how the state ultimately classifies the offense and whether a provider avoids formal felony status. Congress designed the exclusion statute to operate independently from state criminal sentencing policies and diversionary arrangements.

Program-related offense. The ALJ rejected the argument that the conviction lacked a sufficient nexus to the delivery of health care services, reasoning that billing Medicaid for services that could not actually have been provided directly implicates the delivery of care under a state health care program. The decision relied on prior federal authority construing the phrase “related to” broadly rather than narrowly. The opinion cited appellate precedent describing the statutory language as “deliberately expansive” and resistant to “crabbed and formalistic” interpretation.

Mandatory exclusion. In addition, once the statutory predicates for exclusion are met, the ALJ explained that federal law required at least a five-year exclusion period. Notably, the Inspector General did not seek an enhanced exclusion period based on aggravating factors. Once the threshold was satisfied, the minimum five-year exclusion became automatic as a matter of law.

Statutory minimum. The caregiver argued that she valued her work and hoped to return to providing personal care services. The ALJ acknowledged those representations sympathetically but concluded that the administrative forum lacked authority to impose anything shorter than the statutory minimum.

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